Provider Demographics
NPI:1972271260
Name:CLARK, CODY (PHARMD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 MCAVOY DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-1960
Mailing Address - Country:US
Mailing Address - Phone:806-773-5958
Mailing Address - Fax:
Practice Address - Street 1:1229 RESERVE BLVD STE 100A
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-3273
Practice Address - Country:US
Practice Address - Phone:931-487-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist